This webinar presentation is brought to you by —a robust health information exchange (HIE) clinical

integration architecture that drives a comprehensive array of care coordination and care management programs and servicedelivery platforms, including a CMS approved Qualified Registry for the abstraction, documentation, verification, andreporting of the full spectrum of payment associated quality performance measures identified in the MACRA QualityPayment Program (QPP). Guardian is your dedicated partner in achieving long-term success and independence underMACRA and the every changing value-based healthcare environment.

A TALE OF TWO PATHS

QUALITY PAYMENT

PROGRAM (QPP)

MEDICARE ACCESS

AND CHIP

REAUTHORIZATION

ACT (MACRA)

• What is the QPP? MACRA? MIPS? Etc.

• What are the Challenges All Physicians Face

• What are the Opportunities Unique to us

• How can Guardian assist you in succeeding under

MACRA

What is MACRA?

The bipartisan Medicare Access and CHIP Reauthorization Act of 2015

(MACRA), commonly referred to as the “Permanent Doc Fix”, is a law

that establishes a dedicated route toward new Medicare payment

systems that align payment with quality performance and cost

efficiency outcomes.

Through 2019 there will be a 0.5% annual increase in the physician fee

schedule.

Any other change in Fee Schedule will be an incentive or penalty

MACRA QPP DIRECTLY IMPACTED CLINICIANS BEGINNING IN 2017—THE TRANSITION YEAR

Physicians (MDs and DOs)

Physician Assistants (PAs)

Nurse Practitioners (NPs)

Clinical Nurse Specialists (CNS)

Certified Registered Nurse Anesthetists

(CRNAs)

Certified Nurse Midwives

Clinical Social Workers

Clinical Psychologists

Registered Dietitians/Nutritionists

Physical Therapists and Occupational

Therapists

Speech/Language Pathologists

Qualified Audiologists

Clinicians subject to MACRA participation in

the 2017 Transition Year include:

Beginning in 2021, CMS can designate

additional clinicians. The MACRA Final

Rule provides the following specific

examples of clinicians who may be

included in the 2012 payment year:

MACRA QPP EXCLUDED CLINICIANS AS OF THE TRANSITION YEAR-2017

Newly enrolled Medicare Clinicians—Clinicians who are in their first Medicare Part B calendar year.

Clinicians below a Medicare patient volume

threshold—Clinicians who:

Have recorded Medicare billing charges of less than

or equal $30,000.

Providing care to 100 or fewer Part-B enrolled

Medicare beneficiaries.

PHYSICIAN AWARENESS OF MACRARecent surveys of physicians who will be directly impacted by MACRA and the expectations of the

MACRA Quality Payment Program (QPP) indicate:

50 % of physicians have never heard of MACRA.

32 % of physicians are acquainted with the name MACRA, but do

not fully understand the requirements or legal components.

20.6 % of primary care physicians and 19.5 % of specialist

physicians were somewhat to very familiar with the law.

Nearly 80 % of physicians prefer traditional fee-for-service or salary-

based compensation, opposed to value-based models.

74 % of physicians believe performance reporting is burdensome.

79 % of physicians do not agree with binding compensation to

quality of care, which is a requirement under MACRA.

Nearly 40% of physicians are more likely to accept risk-based

compensation if they are part of a larger organization.

Despite the expressions of critics, the bi-partisan

MACRA and the QPP generated in the MACRA Final

Rule are reality. The time is NOW for taking action.

Procrastination could prove detrimental to the future sustainability of your practice.

THE MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) PATH

THE INITIAL STAGING OF MIPS

FIRST MIPS PERFORMANCE YEAR

TRANSITION YEAR 2017

DEADLINE FOR SUBMITTING

TRANSITION YEAR DATA

MARCH 31, 2018

CMS PERFORMANCE FEEDBACK MID TO

LATE 2018

MIPS PAYMENT ADJUSTMENT +/-BASED ON 2017

PERFORMANCE DATA JANUARY 1, 2019

MIPS PARTICIPATION AS AN INDIVIDUAL CLINICIAN OR AS A GROUP OF CLINICIANS?

The group will receive one payment

adjustment based on the entire

group’s performance.

The group will be required to send

group level data for each of the MIPS

performance categories through a

CMS web interface, and/or EHR,

and/or CMS approved Qualified

Registry. (NOTE: To submit data

through a CMS web interface, the

group must register as a group by

June 30, 2017.)

Your payment adjustment will be based

entirely on your MIPS performance.

You will be required to send your

individual data for each of the MIPS

performance categories via an EHR,

and/or a CMS approved Qualified

Registry.

If you engage as an individual MIPS eligible

clinician (identified as a single National

Provider Identifier-NPI):

If you engage as a group (identified as a set

of eligible clinicians with individual NPIs

sharing a common Tax Identification

Number independent of specialty or

practice site):

THE FOUR PIECES OF THE MIPS PAYMENT PUZZLE—

THE MIPS PERFORMANCE CATEGORIES COMPOSITE PERFORMANCE SCORING (CPS) METHODOLOGY

MIPS is composed of the following four distinct Performance Categories.

The MIPS unified scoring

system results in the

calculation of a MIPS

Composite Performance Score

(CPS) for all MIPS eligible

clinicians that represents

performance in the four

categories on a scale of 0-100 points.

Each performance category is assigned a weighted value, which can

change each performance year.

THE MIPS QUALITY PERFORMANCE CATEGORY

The Final Rule identifies a quality performance measurement set composed

of 271 measures from which MIPS eligible clinicians can select the specific

measures they wish to report.

The total MIPS quality measurement set is organized into subsets along

specialty lines with the largest number of measures falling into the primary

care provider subset.

THE MIPS QUALITY PERFORMANCE CATEGORY

Requirements for MIPS eligible clinicians reporting as

individuals or as a group reporting via a non-web

interface (i.e., Qualified Registry, Qualified Clinical Data Registry, claims, and/or EHR):

Must report on at least six quality measures with at least

one being an outcome measure, or if an outcome

measure is not available, a high priority measure.

THE MIPS QUALITY PERFORMANCE CATEGORY

Requirements for MIPS eligible clinicians reporting as a group via a CMS web interface: (Reporting option for groups of 25 or more)

Must report on all measures included in the CMS web interface (e.g., eligible clinicians participating in a Track 1 Medicare Shared Savings Program (MSSP) ACO will report on

the required performance measures for the ACO through the CMS Group Practice

Reporting Option (GPRO) web interface).

Any measure not reported will be considered zero performance for that measure in the

CMS scoring algorithm.

In 2017, the group is required to report on 15 measures.

In addition to the group reporting on the fifteen measures, groups will be scored on a

claims-based hospital re-admission measure, evaluated and reported by CMS.

The Quality performance category measures will

also be updated annually on or before November 1st each year.

÷ =

x =

Example:

Formula:

÷ =

x =

Formula:

Example:

MIPS RESOURCE USE PERFORMANCE CATEGORY

There is no data submission reporting requirement for MIPS eligible clinician under the Resource Use

Performance Category for the Transition Year (2017).

During the Transition Year (2017) the MIPS Resource Use Performance Category has been reweighted

in the Final Rule to 0%.

Beginning with performance year 2018 (for payment year 2020), MIPS eligible clinicians will be

assessed on their performance of total per capita costs and Medicare spending per beneficiary

(MSPB).

MIPS eligible clinicians will also be assessed on applicable episode-based measures. CMS has

indicated that feedback on these measures will be provided sometime during the 2017 Transition Year.

THE MIPS IMPROVEMENT ACTIVITIES PERFORMANCE CATEGORY

The Improvement Activities Category represents

a NEW CMS performance measurement

approach that supports the broad aims in

healthcare delivery to enhance care

coordination, increase beneficiary engagement,

and expand population management.

THE MIPS IMPROVEMENT ACTIVITIES

Expanded Access to Care: Example activities include providing 24/7 access to advice about urgent &

emergent care; use of telehealth services and analysis of data for quality improvement.

Care Coordination: Example activities implementing standard operations for Transitions of care; timely

communication of test results and follow-up between PCPs and specialists; process for updating and

sharing care plans with and between patient’s, patient’s caregivers; and patient’s clinicians.

Emergency Response and Preparedness: Example activity includes participation in Disaster Medical

Assistance Teams or Community Emergency Responder Teams for a minimum of 6 months.

Achieving Health Equity: Example activities include seeing new and follow-up Medicaid and dual

eligible patients in a timely manner; and participation in Qualified Clinical Data Registry (QCDR)

demonstrating use of standardized processes and screening for social determinants of health.

THE MIPS IMPROVEMENT ACTIVITIES

Population Management: Example activities include provide longitudinal care management to at-risk

patients; manage medications to maximize efficiency, effectiveness, adherence and safety; take steps to

improve the health status of communities.

Beneficiary Engagement: Example activities include access to an enhanced patient portal; use of

evidence-based decision aids to support shared decision-making; engagement of patients and

caregivers in the development of care plans; use of patient engagement tools; provide peer-led support

for self-care management.

Patient Safety and Practice Assessment: Example activities include building analytic capability required to

manage total cost of care for a practice population, including on-going analysis of data leading to cost

efficient care; implement fall screening and assessment programs to identify patients at risk for falls and

address modifiable factors; use of tools such as the Surgical Risk Calculator.

Integrated Behavioral and Mental Health: Activities include tobacco intervention and smoking cessation

efforts; routine depression screening and follow-up; integration behavior health services to support patients

with behavioral health needs.

THE MIPS IMPROVEMENT ACTIVITIES

Each of the 92 activities groups in the eight sub-

categories are scored as High (20 points) or

Medium (10 points).

For the Transition Year (2017) clinicians are required

to attest to performing four medium weighted or

two high weighted activities to receive full credit in

the Improvement Activity Category.

Clinicians participating in a Patient-Centered

Medical Home (PCMH) or a MIPS APM (to be

discussed later in the presentation) will

automatically receive full credit for the

Improvement Activities Category. NOTE: If one

practice under the TIN has PCMH recognition, the

entire TIN will qualify for full points this performance

category.

Formula:

Example:

Formula:

+ =

÷ = X

THE MIPS ADVANCING CARE INFORMATION (ACI) PERFORMANCE CATEGORY

The MIPS Advancing Care Information (ACI) Performance Category provides a

facelift to the Medicare EHR Incentive Program, otherwise known as Meaningful

Use (MU). The notable changes to the MU Program under this MIPS Performance Category include:

The MU is no longer an “all-or-nothing” program. MIPS eligible clinicians must report the base

measures, but do not have to report all of the measures available.

Removal the MU threshold requirements. MIPS eligible clinicians do not have to meet a certain

percentage.

Reduced Public Health Registries reporting requirements. Immunization reporting is no longer

required but can still be selected for performance points.

The facelift retires 2 existing MU measures--the Computerized Physician Order Entry (CPOE) and

Clinical Decision Support measures.

For the 2017 Transition Year, there are two distinct MIPS Advancing Care

Information (ACI) Performance Category measurement sets for reporting data,

depending upon the edition of the certified electronic health record

technology (CEHRT) used by a MIPS eligible clinician for the 2017 performance

reporting period.

THE MIPS ADVANCING CARE INFORMATION (ACI) PERFORMANCE CATEGORY

BASE SCORE OBJECTIVES AND MEASURES--There are 5 MIPS ACI Performance Category Base Score

objectives and measures. These objectives and measures represent a core level of MIPS ACI

participation and, as such must be completed in entirety (all five measures) by all MIPS eligible clinicians.

Failure to meet the base score requirements results in a score of 0 for the entire Advancing Care

Information Performance Category. Each of the 5 ACI base measures contribute10 points toward the

overall ACI score. The ACI base objectives and measures include:

THE MIPS ADVANCING CARE INFORMATION (ACI) PERFORMANCE CATEGORY

# BASE OBJECTIVE* BASE MEASURE POTENTIAL %--POINTS

1 Protect Patient Health Information Security Risk Analysis 10 Points

2 Engage in Electronic Prescribing EPrescribing 10 Points

3 Provide Patient Electronic Access Patient Electronic Access 10 Points

4 Health Information Exchange Send Summary of Care Report 10 Points

5 Health Information Exchange Request/Accept Summary of Care Report 10 Points

PERFORMANCE SCORE OBJECTIVES AND MEASURES--To achieve an overall ACI performance score above

the Base Score, MIPS eligible clinicians may choose to report on one or more of a set of nine (9)

Performance Score Objectives and Measures for a minimum of 90 days during the Transitional reporting

period (2017). The ACI performance objectives and measures include:

THE MIPS ADVANCING CARE INFORMATION (ACI) PERFORMANCE CATEGORY

# PERFORMANCE OBJECTIVE* PERFORMANCE MEASURE POTENTIAL %--POINTS

N/A Provide Patient Electronic Access** Patient Electronic Access Up to 10 Points

N/A Health Information Exchange** Send Summary of Care Report Up to 10 Points

N/A Health Information Exchange** Request/Accept Summary of Care Report Up to 10 Points

**NOTE: The three measures identified in red in the performance set are included in both the

Base Score measurement set and Performance Score measurement set. For these measures

eligible clinicians only need a 1 in the numerator for the Base Score, but will earn additional

points toward the performance score for higher values in the numerator in each the measures.

THE MIPS ADVANCING CARE INFORMATION (ACI) PERFORMANCE CATEGORY

# PERFORMANCE OBJECTIVE* PERFORMANCE MEASURE POTENTIAL %--POINTS

6. Provide Patient Electronic Access Patient Specific Education Up to 10 Points

7. Care Coordination Through Patient Engagement

View, Download, and Transmit VDT Up to 10 Points

8. Care Coordination Through Patient Engagement

Secure Electronic Messaging Up to 10 Points

9. Care Coordination Through Patient Engagement

Patient Generated Health Data Up to 10 Points

10. Clinical Information Reconciliation Clinical Information Reconciliation (medications, allergies, problem list)

Up to 10 Points

11. Public Health Reporting Immunization Registry Reporting 10 Points for YES Attestation

BONUS SCORE MEASURES: In addition to the Base Score and Performance Score

objectives and measures, eligible MIPS eligible clinicians can accumulate an additional ACI Performance Category score through bonus points. Provider can

receive up to 15 points by:

THE MIPS ADVANCING CARE INFORMATION (ACI) PERFORMANCE CATEGORY

Reporting data to one or more public health or clinical data registries beyond the Immunization

Registry Reporting measure. (5 additional ACI points). This bonus is only available to MIPS eligible

clinicians who earn a Base Score, and does not require reporting the Immunization Registry

Reporting Performance measure to earn the 5 points.

Attesting YES to completing at least one of the qualified improvement activities from the MIPS

Improvement Activities Performance Category using a CEHRT. (10 additional bonus points). The

additional bonus points are available whether the MIPS eligible clinician attests to using CEHRT for

one or more of the qualified activities, with the weight of the activities having no bearing on the

bonus award.

ACI measures can be reported via EHR, Qualified Registry (QR), Qualified

Clinical Data Registry QCDR), and attestation. The ability to report ACI

measures via a QR or a QCDR is new under MIPS. CMS has stated in

numerous MIPS related publications they are encouraging consolidation of

reporting for all categories through a single submission mechanism (e.g.,

Qualified Registry)

THE MIPS ADVANCING CARE INFORMATION (ACI) PERFORMANCE CATEGORY

EHR

QR QCDR

Formula:

Example:

Formula:

+ + =

÷ x =

MIPS “PICK YOUR PACE” OPTIONS FOR THE 2017 TRANSITION YEAR

For the MIPS Transition Performance Reporting Year (2017), CMS is allowing

MIPS eligible clinicians the following “pick your pace” options:

MIPS ECONOMICS—NEGATIVE/POSITIVEPAYMENTS AND INCENTIVES OVER TIME

MIPS PERFORMANCE TRANSPARENCY

MIPS performance carries with it potential positive or negative consequences for an MIPS eligible

clinician’s reputation.

Within approximately 12 months of the end of a performance period, CMS will publish each provider’s

MIPS score and component category scores to the Physician Compare website.

For the first time, consumers will have access to see how their clinicians are rated on a scale of 0 to

100 and how their clinicians compare to peers nationally.

This level of transparency and specificity goes beyond existing programs such as the PQRS Value

Based Payment Modifier (VBM), which calculates quality and resource use scores but does not

publicly publish the results.

MIPS PERFORMANCE TRANSPARENCY

Physician Compare will also release the scores in a freely downloadable and structured format (such

as an Excel document or text file), as is currently done for PQRS measure data.

CMS will publish national aggregate information about the MIPS score, including the national average

score and the range of scores for all MIPS eligible clinicians.

Given the range of clinicians impacted by MIPS, for many of these clinicians, the MIPS score will be the

first time their public reputation may be impacted by a 100-point scale placed on a national

comparison platform and distributed to an audience of potentially millions.

THE ALTERNATIVE PAYMENT MODELS (APMs) PATH

What is an APM?

An Alternative Payment Model (APM) is

a payment approach that gives added

incentive payments to provide high-

quality and cost-efficient care. APMs

can apply to a specific clinical

condition, a care episode, or a

population.

What is an AAPM?

The criteria for an Advanced Alternative Payment Model in the QPP include:

The APM is a CMS Innovation center model, or a select CMS Innovation Center Shared

Saving Program track.

The APM Require participants to use CEHRT.

The APM reports and bases payments for services on quality measures comparable to

those in MIPS.

The APM is a Medical Home Model expanded under the Innovation Center authority OR the APM requires participants to bear more than nominal financial risk for losses.

Advanced APMs are a subset of APMs, and let practices earn more

for taking on some risk related to their patients' outcomes. You may

earn a 5% incentive payment by going further in improving patient

care and taking on risk through an Advanced APM.

MACRA QPP DIRECTLY IMPACTED CLINICIANS BEGINNING IN 2017—THE TRANSITION YEAR

Medicare Shared Savings Program (MSSP)

Tracks 2 & 3

Next Generation ACO Model

Comprehensive ESRD Care Model, Large

Dialysis Organization (LDO) arrangement

and non-LDO two-sided risk arrangement

Oncology Care Model (2-sided risk

arrangement only)

Chronic Care for Joint Replacement CEHRT

(Track 1)

Comprehensive Primary Care Plus (CPC+)

For the 2017 Transition Performance Year

CMS has approved the following to be

classified as Advanced APMs:

In future years beginning in 2018, CMS has

proposed in the Final Rule the roll-out of the

following additional Advanced APMs:

ACO Track 1+

New voluntary bundled payment model

Comprehensive Care for Joint Replacement

Payment Model (Certified Electronic Health

Record Technology (CEHRT) track)

Advancing Care Coordination through

Episode Payment Models Track 1 (CEHRT)

Benefits of being in an AAPM

QUALIFYING PARTICIPANT (QP) IN A CMS ELIGIBLE ADVANCED APM

A provider’s QP status is determined by his or her participation in a CMS approved Advanced APM

entity that collectively meets the following revenue or patient thresholds for the QPP transition year

(2017):

Minimum Revenue Threshold –The collective Part B payments for Medicare Part B services delivered

by the Advanced APM entity’s clinicians to Medicare patients who are attributed to that entity

represents at least 25% of the total payments for Medicare Part B professional services.

Minimum Patient Count Threshold Requirement—The collective number of patients attributed to the

Advanced APM who received Medicare Part B services delivered by the entity’s clinicians

represents at least 20% of the total number of all patients who received Medicare part B professional

services from the Advanced APM.

STRADDLING THE MIPS AND ADVANCED APM PATHS—THE MIPS APM

Under the MIPS APM Scoring Standard:

CMS will award the same final MIPS score to all participants in a MIPS APM entity---including for data

they reported individually or as a group under a single TIN.

Since the CMS approved MIPS APMs are already assessed collectively for meeting certain quality and

cost metrics, CMS will score the Advancing Care Information and Improvement Activities collectively as

well.

CMS will use an average score for all the participants’ scores for Advancing Care Information to

determine a group score.

ALL participants in a qualified MIP APM will receive the same total available score for Improvement

Activities.

A UNIQUE OPPORTUNITY ON THE HORIZON

On December 20, 2016 CMS announced a new Innovations Center Model—The Medicare

Accountable Care Organization (ACO) Track 1 + Model.

This new model incorporates limited downside risk to encourage more practices to

advance to performance-based risk.

Beginning in 2018, the Track 1 + Model will be classified as an Advanced APM providing an

avenue for clinicians to earn Incentive Payments under the MACRA

THE TRACK 1+ ACO MODEL:

Prospective beneficiary assignment

Introduction of downside risk that is lower than existing ACO Tracks.

Provides an option to request a Skilled Nursing Facility (SNF) 3-Day Rule Waiver to provide greater

flexibility to coordinate and deliver high quality care.

Is designed an “on-ramp” in the progression to two-sided risk.

The new Track 1+ Model will be available to new ACOs and

ACOs currently in Track 1.

FACS is Morphing for a Track 1+ ACO for Increased QPP

Bonuses

THE FACTS--

The challenges of MACRA and the payment

paths under the Quality Payment Program

(QPP) are real and upon us.

To survive and flourish under the MACRA QPP clinicians/practices must commit and be

connected.

Impacted clinicians must be able to align their practice with technology that provides

interoperability, the edge to engage in real-

time clinical integration, care coordination,

and care management, and an efficient

avenue for compliant documentation and reporting to CMS across the four performance

categories.

THE FACTS--

In a July 23, 2016 article in Modern Healthcare, entitled, With MACRA Looming, Doctors

Can’t Waiting to Plumb its Intricacies, the author, Howard Wolinsky stated:

“Meaningful use is first-grade arithmetic and MIPS and MACRA are

college-level calculus—it is very complex.”

Sorting through and implementing timely responses to the exigencies of the MACRA QPP represents a formidable task.

The challenge is not simply to survive, but rather to thrive.

THE SOLUTION:Guardian and Guardian Care Management offers

MACRA QPP impacted clinicians the following

compliant solutions they need to ensure a successful

and financially rewarding transition into and through the long-term staging of MACRA and the QPP:

Web-based, Clinically Integrated, interoperable and customized for you

Operates at an enterprise-grade level of functionality

Secure and Easy to use, it provides fast-track implementation for

clinicians/practices Designed to ensure compliance with all documentation and reporting

requirements of the QPP - MIPS

A CMS Approved MIPS

Qualified Registry that is: